Infertility: It’s Not Just a Female Problem

People often assume that infertility is a problem that is most likely to affect women. In fact, in almost half the cases, male infertility plays at least a partial role, according to Raevti Bole, MD, a urologist specializing in male reproductive and sexual medicine at the Cleveland Clinic in Cleveland, OH.

“When a male partner is having infertility problems, a urologist can be helpful in many ways,” Dr. Bole said. “A urologist can provide solutions that will help a couple conceive, from uncovering the causes of infertility to providing treatments.” 

Infertility Basics 

An estimated 10-15% of couples across the world who are trying to conceive a child experience infertility. Infertility is defined as having unprotected sex for one year without getting pregnant. 

It is well known that as a woman gets older, fertility declines. A woman is most fertile when she is between her late teens and late 20s. A woman’s fertility begins to decline by age 30. The drop in fertility increases once a woman reaches her mid-30s. A healthy fertile woman trying to get pregnant in her 20s and early 30s has around a 25% chance of success each month. By age 40, that declines to about 10%. For most women, getting pregnant is not common by age 45. 

Men’s fertility can also decline as they age, starting between age 40 and 50. “We begin to see changes in the quality and quantity of sperm as a man ages,” Dr. Bole said. “That affects a man’s ability to conceive a child. It also increases the risk of miscarriage.” 

Sperm can also be affected by other health factors. These include illness, injuries and chronic health problems. Using tobacco, marijuana or cocaine can also affect sperm.

Dr. Bole says that if a couple cannot get pregnant after a year of trying, both partners should get tested for fertility issues. “Men should be tested by a urologist, while women should see a gynecologist,” she said. “If the woman appears to have fertility problems, she will be referred to a reproductive endocrinologist. This is an OB GYN doctor who specializes in female fertility.” 

How a Urologist Can Help

A urologist examining a male patient for infertility will do a physical exam. The doctor will consider the man’s age and health conditions. Fertility can be affected by many things. These include diabetes, obesity, a history of cancer or some drugs. Drugs that affect fertility include testosterone replacement therapy, long-term anabolic steroid use, chemotherapy, some ulcer drugs and some arthritis drugs.

In about 80% of cases, a doctor will be able to find the cause of a man’s infertility. 

Other possible causes may include:

Hormone imbalances. The doctor may suggest hormone replacement or drugs when infertility is caused by high or low levels of certain hormones or problems with the way the body uses hormones.

Varicocele. This is a swelling of the veins that drain the testicle. It's the most common reversible cause of male infertility. Varicoceles may lead to reduced sperm quantity and quality. Surgery to treat the condition has a good success rate for improving sperm problems, but not all varicoceles cause fertility issues. 

Undescended testicle. This occurs when a baby's testicles have not moved into the proper position. This can affect fertility later in life. In most cases, the testicle drops on its own by about six months after birth. If it doesn’t, the condition can be fixed through surgery. Men with one undescended testicle can still have children, but their fertility is lower than normal by about half. If they have surgery to correct it, especially when they are younger, their fertility is about the same as if they never had a problem.

Testicular cancer. This is the most common cancer in young men. “At least half of men with testicular cancer have some kind of sperm problems when they are diagnosed, even before treatment,” Dr. Bole said. “Treatment itself can also damage testicles and affect sperm production.” She suggests that when possible, men should have their sperm frozen before treatment. This is called sperm banking.

In some cases, it may be possible to extract sperm at the time of surgery, Dr. Bole said. “If we remove the testicle with cancer in it, we can try to take normal tissue from the non-cancerous area to preserve sperm.” Some men are able to start making sperm again after they recover from treatment. About three-quarters of testicular cancer survivors can naturally conceive a child. About one-fourth of men with testicular cancer who want children use some form of reproductive technology such as in vitro fertilization (IVF) to have children.

Obesity. Excess weight can cause imbalances of the hormones, including testosterone and estrogen. Males need a certain amount of testosterone inside the testicles to make a healthy amount of sperm. Healthy weight loss may also improve sperm count and quality. 

Certain genetic conditions. These include Klinefelter syndrome, which occurs when a boy is born with an extra copy of the X chromosome. It often isn’t diagnosed until adulthood. “Some men don’t get diagnosed until they are trying to have a child, and we find their infertility is caused by this condition,” Dr. Bole said.

Treatment for other types of cancer. Radiation therapy to - or near - the abdomen, pelvis or spine can harm nearby reproductive organs. Some types of chemotherapy can affect fertility, at least in the short term. 

Spina bifida. This rare condition affects the spine. Most people with spina bifida are fertile and can have children. Males with spina bifida may have problems with making sperm. Based on what part of the spinal cord is affected, males may have problems with ejaculation or erections. If this happens, the doctor may be able to extract sperm and fertilize an egg from their partner. 

Transgender patients. Based on when a person chooses to undergo gender-affirming care, they may not yet be thinking about having biological children, Dr. Bole said. “When someone is born male and transitions to female, we advise them to think about banking their sperm before they start medical treatment, or before permanent surgical treatment,” she said. “That way, when they are ready to think about having children, they will have options available.” 

There are lifestyle choices that men can make to boost their fertility, Dr. Bole said. “These include avoiding illicit drugs and excessive alcohol, not smoking and keeping a healthy weight.” For men whose infertility is caused by medical conditions, there are treatment options in many cases. “Talk to your urologist about the options for you and your partner to conceive a child,” Dr. Bole said.